A bronchoscopy is a specialized medical procedure used to visualize and assess the airways and lungs. By inserting a thin, flexible or rigid tube equipped with a camera and light into the trachea, healthcare providers can diagnose, monitor, and sometimes treat various respiratory conditions.
This minimally invasive technique is essential for identifying infections, lung diseases, and obstructions, as well as performing therapeutic interventions such as mucus removal or tumor excision.
While generally safe, bronchoscopy does carry some risks, including minor bleeding, infection, or airway irritation. This article will explore the procedure in detail, including its types, indications, risks, and what to expect before and after the exam.
What is a Bronchoscopy?
A bronchoscopy is a medical procedure that allows healthcare providers to visually examine the airways, including the trachea and bronchi, using a specialized instrument called a bronchoscope. This procedure is commonly performed by a pulmonologist or thoracic surgeon to diagnose, monitor, or treat various lung conditions.
During the procedure, a bronchoscope—a thin, flexible tube equipped with a camera and light—is inserted through the nose or mouth and carefully guided down the throat into the airways. This enables the provider to inspect the lungs and perform necessary interventions.
Indications
Bronchoscopy serves both diagnostic and therapeutic purposes, including:
- Diagnosis: Detecting infections, tumors, inflammation, bleeding, or airway abnormalities.
- Tissue and Fluid Collection: Obtaining lung tissue biopsies or bronchoalveolar lavage (BAL) samples for further testing.
- Treatment: Removing foreign objects, clearing mucus plugs, controlling bleeding, or delivering medications directly to the lungs.
Types of Bronchoscopy
There are two main types of bronchoscopy:
- Flexible Bronchoscopy: The most commonly used method, involving a flexible bronchoscope. It is typically performed under local anesthesia with sedation for patient comfort.
- Rigid Bronchoscopy: Uses a rigid metal bronchoscope and is performed under general anesthesia. This method is less common but may be necessary for certain procedures, such as removing large obstructions or managing severe bleeding.
Note: Bronchoscopy is generally a safe and well-tolerated procedure. However, potential risks include mild bleeding, infection, airway irritation, or reactions to anesthesia. These risks are rare, and the benefits of the procedure often outweigh them, especially when diagnosing or treating serious lung conditions.
Respiratory Therapist’s Role During a Bronchoscopy
The role of a respiratory therapist in a bronchoscopy procedure is crucial for ensuring patient safety, maintaining airway patency, and assisting with both diagnostic and therapeutic interventions.
While their level of involvement may vary depending on the healthcare setting, their primary responsibilities include equipment preparation, patient monitoring, and procedural assistance.
Before the Procedure
Prior to the bronchoscopy, respiratory therapists play an essential role in patient assessment and preparation, ensuring a smooth and safe procedure. Their duties include:
- Assessing the Need for Bronchoscopy: RTs help determine if the procedure is necessary by identifying potential indications, such as retained secretions, suspected lung infections, persistent atelectasis, hemoptysis, or foreign body aspiration.
- Reviewing Patient History: They check the physician’s order, evaluate the patient’s medical record for contraindications (e.g., severe hypoxia, unstable hemodynamics, bleeding disorders), and ensure informed consent is obtained.
- Equipment Preparation: RTs set up and check all necessary equipment, including: The bronchoscope (ensuring proper function and sterilization). Suction systems for secretion removal, oxygen delivery devices (nasal cannula, mask, or high-flow systems) to maintain adequate oxygenation, aerosolized bronchodilators (if needed) to reduce airway resistance and minimize bronchospasm risk, and monitoring equipment (pulse oximeter, capnography, blood pressure cuff, and ECG).
- Pre-Procedural Medication Administration: If indicated, RTs may administer aerosolized bronchodilators to reduce airway resistance and facilitate smoother bronchoscope passage.
During the Procedure
During the bronchoscopy, respiratory therapists assist in multiple ways to ensure patient stability and procedural efficiency:
- Vital Sign Monitoring: RTs continuously monitor the patient’s heart rate, blood pressure, oxygen saturation (SpO₂), and end-tidal CO₂ to detect any early signs of hypoxia, bronchospasm, or hemodynamic instability.
- Oxygen Administration and Airway Management: They provide supplemental oxygen or noninvasive ventilation as needed to maintain adequate oxygenation levels, especially for patients with preexisting respiratory compromise.
- Patient Positioning: RTs help adjust the patient’s position to optimize airway visualization and procedural success.
- Assisting with Equipment and Accessories: They manage and assist with various bronchoscopy accessories, such as: Bite blocks and oral airways to prevent injury, nasopharyngeal tubes for easier scope passage, biopsy forceps and brushes for sample collection, and suction catheters to remove secretions or blood from the airway.
- Recognizing and Responding to Complications: If adverse reactions occur (e.g., desaturation, laryngospasm, or hypotension), RTs assist in stabilizing the patient by adjusting oxygen delivery, suctioning secretions, or preparing for emergency airway interventions if necessary.
After the Procedure
Post-procedure care is just as important as the bronchoscopy itself. Respiratory therapists help ensure a smooth recovery by:
- Maintaining Airway Clearance: Encouraging deep breathing and coughing exercises to help clear residual secretions and minimize post-procedure atelectasis.
- Providing Oxygen Therapy: Administering supplemental oxygen as needed to prevent post-procedure hypoxia, especially in patients with preexisting lung disease.
- Ongoing Monitoring: Closely observing the patient for any delayed complications, such as persistent hypoxia, increased work of breathing, hemoptysis (coughing up blood), and stridor or respiratory distress.
- Documenting the Procedure: RTs are responsible for accurately recording vital signs, oxygen administration, interventions performed, and any notable patient responses in the medical record. They also communicate findings or concerns to the physician for further evaluation.
Note: Respiratory therapists play a vital role throughout the bronchoscopy process, ensuring patient safety, procedural success, and effective post-procedure recovery. Their expertise in airway management, oxygen therapy, and patient monitoring makes them an essential part of the bronchoscopy team.
Bronchoscopy Practice Questions
1. What is flexible bronchoscopy used for?
It can be used for diagnostic and therapeutic purposes; however, it is most often indicated to help with the diagnosis of pulmonary diseases.
2. What is the goal of sedation during a bronchoscopy?
It improves the patient’s comfort during the procedure.
3. The continuous monitoring of what is important during a bronchoscopy procedure?
The monitoring of oxygenation and hemodynamic stability is important.
4. What are the most commonly used diagnostic procedures in flexible bronchoscopy?
BAL, biopsy, and TBNA.
5. BAL obtains samples from what?
The alveoli
6. Needle aspiration has a role in sampling mediastinal lymph nodes to diagnose what?
Lung cancer, sarcoidosis, and some infectious processes.
7. A biopsy has value in the diagnosis of what?
Infiltrative pulmonary diseases
8. What is often used along with a flexible bronchoscopy?
Various thermal ablation techniques
9. When using thermal ablation techniques, what is the most important thing to remember?
You should ensure a low FiO2 environment before the use of any thermal ablative therapy.
10. When can airway stenting be used to maintain airway patency?
It is used after the dilation of any obstructed major airways, and it’s important to recognize the difference between silicone and metallic stents.
11. What is bronchial thermoplasty?
It’s a novel bronchoscopic technique for patients with steroid-dependent asthma.
12. What is being studied in the management of patients with severe emphysema as a minimally invasive lung volume reduction therapy?
Endobronchial valves and coil placement
13. Who plays a vital role in assisting before, during, and after bronchoscopy?
Respiratory therapists
14. How does a respiratory therapist help with a bronchoscopy procedure?
There are many aspects to this role, but they include ensuring appropriate documentation (e.g., physician’s order), preparing the patient and the equipment, patient monitoring, and responding to adverse events.
15. What special considerations should be made when performing a bronchoscopy on mechanically ventilated patients?
Patients on the ventilator are more susceptible to adverse events. These considerations include ensuring adequate ventilation and gas exchange before, during, and after the procedure.
16. What are the clinical situations where flexible bronchoscopy would be indicated?
Hemoptysis, wheezing and stridor, pulmonary infiltrates, unexplained lung collapse, suspected or known bronchogenic carcinoma, mediastinal and hilar lymphadenopathy, lung transplantation, endotracheal intubation, evaluation of foreign body aspiration, unexplained superior vena cava syndrome, unexplained vocal cord paralysis, suspected fistulas, and treatment of refractory asthma.
17. What are the absolute contraindications for flexible bronchoscopy?
Refractory hypoxemia, lack of patient cooperation, lack of skilled personnel, lack of appropriate equipment and facilities, unstable angina, uncontrolled arrhythmias, increased intracranial pressure, and uncorrectable bleeding diathesis.
18. What are the relative contraindications for flexible bronchoscopy?
Unexplained or severe hypercarbia, uncontrolled asthma attack, lack of patient cooperation, uncorrected coagulopathy, recent myocardial infarction, unstable cervical spine, impaired neck mobility, and the need for a large tissue specimen.
19. Is sedation important during a flexible bronchoscopy procedure?
Yes, the goal of sedation is to improve the patient’s comfort during the procedure. In addition to risks of arrhythmias and fluctuations in blood pressure related to the procedure, airway manipulation during bronchoscopy may lead to coughing, hypoxemia, vomiting, bleeding, laryngospasm, and bronchospasm. All of these responses can affect the outcomes of the procedure. Therefore, adequate sedation is an essential part of the procedure.
20. What is BAL, and when is it indicated?
BAL stands for Bronchoalveolar lavage. It is used to obtain specimens from the alveolar region of the lung.
21. When is rigid bronchoscopy indicated?
Although the role of rigid bronchoscopy (RB) has declined, it remains an invaluable tool for the control of a compromised airway, massive hemoptysis, silicone stent placement, and for removing asphyxiating foreign bodies. The primary indication for rigid bronchoscopy is for managing a central airway obstruction.
22. What is the difference between BAL and bronchial washings?
Bronchial washings are generally obtained for the cytological examination of cancer and for microbiological analysis to diagnose mycobacterial or fungal infections. Unlike BAL, bronchial washings are obtained from the large airways.
23. What should a respiratory therapist consider regarding oxygen delivery during thermal ablation?
During the application of “hot therapies” (thermal ablation) like a laser, electrosurgery, or argon plasma coagulation, the FiO2 should always be maintained below 40% to prevent endobronchial ignition.
24. What are endobronchial stents used for?
Stents are devices designed for internal splinting of the airway lumen. Airway stents have been used to help reduce airway obstruction from malignant or benign processes that compress the airway from the outside. Airway stenting can offer immediate relief of acute respiratory distress, allow successful extubation, and may prolong survival.
25. What is the definition of bronchoscopy?
It is the process of passing a bronchoscope into the airways for either diagnostic testing or therapeutic purposes.
26. What are the four types of bronchoscopy?
Flexible bronchoscopy (FB), Rigid bronchoscopy (RB), Diagnostic bronchoscopy (DB), and Therapeutic bronchoscopy (TB)
27. A rigid bronchoscopy is preferred under what conditions?
It is preferred when the patient is under deep sedation with muscle relaxation.
28. What are the risks of flexible bronchoscopy?
Arrhythmias, fluctuations in blood pressure, and airway manipulation during bronchoscopy may lead to coughing, hypoxemia, vomiting, bleeding, laryngospasm, and bronchospasm.
29. What maneuver is used if the patient becomes over-sedated during a bronchoscopy procedure?
The chin-lift and jaw-thrust maneuver may be used.
30. What is recommended to prevent the patient from slipping into deep sedation?
Capnography monitoring while performing flexible bronchoscopy under moderate sedation is recommended.
31. What does flexible bronchoscopy monitoring consist of?
You must keep track of patient responses to verbal commands or spontaneous movements. Their chest movement may continue despite a near-total obstruction of the airway. There should be continuous cardiac, blood pressure, and pulse oximetry monitoring. Capnography should be used to monitor and prevent the patient from entering deep sedation.
32. What are the types of therapeutic bronchoscopy?
Rigid bronchoscopy, thermal ablation of the endobronchial lesion, brachytherapy, cryotherapy, and endobronchial stents.
33. What is the major indication for rigid bronchoscopy?
Managing central airway obstructions
34. What are the three types of thermal ablation of an endobronchial lesion?
Endobronchial electrocautery, argon plasma coagulation (APR), and laser photocoagulation.
35. What are the risks of thermal ablation of an endobronchial lesion?
Improper use of thermal modalities can lead to perforation of the airway, vascular structures, or the esophagus.
36. What are the complications of thermal ablation of an endobronchial lesion?
Hypoxemia, pneumothorax, and bronchopleural or bronchoesophageal fistula.
37. What are the contraindications of thermal ablation of an endobronchial lesion?
Refractory hypoxemia and extrinsic compression of the airway without an endobronchial lesion.
38. What is the relation between flexible bronchoscopy and an endotracheal tube?
You can use a flexible bronchoscope to place an ET tube through the mouth or nose. It allows for awake intubations with topical anesthesia. It is used in patients with cervical injuries where immobilization of the neck is crucial. It may also help identify causes of acute hypoxia and help remove secretions from the airway. It is limited to the experience of the operator, and there must be patient cooperation.
39. What is the respiratory therapist’s role in bronchoscopy before the procedure begins?
Respiratory therapists help identify the potential need for bronchoscopy (retained secretions or foreign body removal). They verify the physician’s order or protocol and review the patient’s record for contraindications (excessive clotting times), hazards, and informed consent. They prepare/ensure the proper function of equipment. They outline a plan for adequate oxygenation during the procedure. They evaluate the patient for bronchospasm and administer aerosolized bronchodilators if required. They assist nurses in the application of topical anesthetics.
40. What is the respiratory therapist’s role in bronchoscopy during the procedure?
Respiratory therapists monitor the patient’s vital signs (including capnography). They help identify and respond to adverse reactions and administer oxygen as needed. They provide proper positioning of the patient and assist with the use of accessories (bite block, oral airways, nasopharyngeal tube, biopsy forceps, brushes, etc.) They set up instruments for rigid bronchoscopy and silicone stents and help place chest tubes or ET tubes in emergency situations.
41. What does a respiratory therapist do during a bronchoscopy of a patient who is receiving mechanical ventilation?
Respiratory therapists help determine the appropriate length and diameter of the ET or tracheostomy tube. They ensure that the bite block is in place to avoid equipment damage. They adjust ventilator settings for safety reasons and oxygenation purposes and then return settings back to the patient’s pre-procedure settings.
42. What are the main complications and risks of a bronchoscopy procedure?
Bleeding, infection, bronchial perforation, bronchospasm, laryngospasm, and pneumothorax.
43. The endoscope reaches what generation of bronchi?
4th–5th
44. What is a rigid tube?
It’s an open metal tube with a distal light source and port for oxygen/ventilating equipment.
45. Who uses the rigid tube?
Otorhinolaryngologists and thoracic surgeons
46. What type of bronchoscope do respiratory therapists most often assist with?
Flexible fiberoptic
47. Which bronchoscope can access very small airways?
Flexible fiberoptic
48. What are the channels in a flexible fiberoptic bronchoscope?
Light transmission, visualizing, and multipurpose open
49. Who uses the flexible fiberoptic bronchoscope?
The pulmonologist, along with assistance from a respiratory therapist.
50. What is the most common method of anesthesia during a bronchoscopy?
The use of a topical anesthetic is the most common.
51. What is the purpose of bronchoscopy?
Bronchoscopy allows a physician or therapist to visualize the trachea and bronchi.
52. What are the diagnostic indications for bronchoscopy?
Suspected foreign-body, suspected malignancy, bronchial washings, hemoptysis, and persistent respiratory problems.
53. What are the therapeutic indications for bronchoscopy?
Foreign-body removal, secretion clearance, bronchial lavage, airway stenosis, and atelectasis.
54. What are the two types of bronchoscopes?
Rigid and flexible.
55. What are the characteristics of a rigid bronchoscope?
A hollow metal tube that functions as an airway, Allows ventilation through the scope during the procedure, Preferred for therapeutic procedures, and Performed in the operating room under general anesthesia.
56. What are the characteristics of a flexible bronchoscope?
A flexible rubber scope with fiberoptic bundles for illumination, Can reach more peripheral airways, Preferred for diagnostic procedures, and Can be performed in an exam room, ICU, or physician’s office under local anesthesia.
57. What type of bronchoscope is recommended for intubated patients with suspected neck fractures?
A flexible bronchoscope.
58. What are the contraindications for bronchoscopy?
Refractory hypoxemia, bleeding disorders, cardiovascular instability, status asthmaticus, and severe hypercapnia.
59. What is the most common complication of bronchoscopy?
Mild epistaxis (nasal bleeding) when using the nasal route.
60. How is localized hemorrhage controlled after a tissue biopsy?
By using saline lavage and allowing time for clot formation.
61. What steps should be taken if serious bleeding occurs during bronchoscopy?
Instill epinephrine, compress the site with the bronchoscope, and insert a Fogarty catheter.
62. How can bronchospasm or laryngospasm be prevented or treated during bronchoscopy?
With bronchodilators and anesthetics.
63. What is a serious hazard associated with bronchoscopy, and how is it monitored and treated?
Hypoxemia, which is monitored using pulse oximetry and ECG and treated with supplemental oxygen.
64. What is a potential complication when taking tissue samples during bronchoscopy?
Pneumothorax
65. How should the bronchoscope be prepared before the procedure?
Check the patency of the scope lumen, ensure the light source is functioning, verify the optical fibers are intact, and confirm the operation of video recording equipment.
66. What equipment is required for bronchoscopy?
Oxygen supply, suction equipment, specimen collection tools (forceps, brush, Lukens trap), and syringes with flush solutions.
67. How is the patient prepared for bronchoscopy?
Administer a topical anesthetic (Lidocaine, Benzocaine, Cetacaine, Novocain), Set up monitoring equipment (pulse oximetry, ECG), Administer a sedative (Midazolam/Versed, Diazepam/Valium, Lorazepam/Ativan), and Administer a narcotic (Morphine) for analgesic and antitussive effects.
68. What are the preparation steps for patients on mechanical ventilation undergoing bronchoscopy?
Ensure a minimum ET tube size of 8.0 mm for flexible bronchoscopy, Obtain a Bodai adaptor to maintain positive pressure ventilation, Administer topical anesthetic through the ET tube, Increase FiO2 to 100%, and Adjust the high-pressure alarm setting.
69. What steps should be taken to clean and disinfect the bronchoscope after the procedure?
Wipe the exterior with a soft cloth or brush, Irrigate and flush the suction channel and port with detergent solution, Rinse the entire instrument with tap water, and Immerse the scope in alkaline glutaraldehyde for disinfection.
70. What allows visualization of the larynx, trachea, and bronchi?
A rigid bronchoscope or a flexible fiberoptic bronchoscope.
71. What does a diagnostic bronchoscopy examination include?
Observation of the tracheobronchial tree for abnormalities, tissue biopsy, and secretion collection for cytologic or bacteriologic analysis.
72. What are the primary purposes of a bronchoscopy?
Inspecting airways, collecting samples, removing foreign objects, and placing devices into airways.
73. What are the different bronchoscopy techniques?
Rigid tube bronchoscopy; flexible fiberoptic bronchoscopy.
74. What are the characteristics of a rigid tube bronchoscopy?
An open metal tube with a distal light source; port for oxygen attachment or ventilating equipment; primarily used by otorhinolaryngologists and thoracic surgeons.
75. What medications are used for premedication before bronchoscopy?
Sedatives to reduce anxiety, anticholinergic agents to dry the airway, and narcotic analgesics to reduce pain.
76. What is the primary goal of preparation before bronchoscopy?
To prevent bleeding, coughing, gagging, and pain.
77. What should be monitored during bronchoscopy?
SpO2, ECG, and vital signs
78. What are the two main categories of bronchoscopy?
Diagnostic and therapeutic
79. What should be done if a patient is experiencing persistent coughing during bronchoscopy?
Administer a local anesthetic to suppress the cough reflex.
80. What safety measures should be taken if an airway obstruction is suspected before bronchoscopy?
Ensure emergency airway equipment, including a rigid bronchoscope and suction, is readily available.
81. What is the primary difference between a rigid and flexible bronchoscope?
A rigid bronchoscope is a hollow metal tube used mainly for therapeutic procedures, while a flexible bronchoscope is a fiberoptic instrument used primarily for diagnostic purposes.
82. What is a major advantage of using a flexible bronchoscope?
It can reach smaller, peripheral airways that a rigid bronchoscope cannot access.
83. Why is general anesthesia required for rigid bronchoscopy?
Because the procedure is invasive, general anesthesia ensures patient comfort and prevents airway reflexes from interfering.
84. Why is bronchoscopy performed under local anesthesia in an ICU setting?
Local anesthesia minimizes discomfort while allowing the patient to maintain spontaneous breathing.
85. What is bronchoalveolar lavage (BAL), and why is it performed?
BAL involves instilling sterile saline into the bronchi and then suctioning it back to collect lung secretions for microbiological and cytological analysis.
86. What is a common indication for bronchoalveolar lavage (BAL)?
Diagnosis of pneumonia in immunocompromised patients, such as those with HIV/AIDS or receiving chemotherapy.
87. How can a bronchoscopy help diagnose lung cancer?
It allows direct visualization of tumors and enables tissue biopsy for histological examination.
88. How is bronchoscopy used to remove foreign bodies?
A rigid bronchoscope is typically used to extract foreign bodies lodged in the airway.
89. Why should a patient fast before undergoing bronchoscopy?
To reduce the risk of aspiration during sedation or anesthesia.
90. What are some post-procedure instructions for a patient after bronchoscopy?
Avoid eating or drinking until the gag reflex returns, monitor for signs of bleeding or infection, and report any breathing difficulties.
91. Why is oxygen administration necessary during bronchoscopy?
To prevent hypoxemia, as the procedure can temporarily impair ventilation.
92. What condition requires urgent bronchoscopy for airway clearance?
Massive hemoptysis (coughing up large amounts of blood).
93. What is a possible complication of bronchoscopy in patients with severe COPD?
Bronchospasm, which can lead to worsening respiratory distress.
94. What should be done if a patient experiences severe coughing during bronchoscopy?
Administer additional local anesthetic or a bronchodilator.
95. How is conscious sedation achieved during bronchoscopy?
Through the administration of benzodiazepines (e.g., midazolam) and opioids (e.g., fentanyl).
96. What is a major contraindication for bronchoscopy?
Unstable cardiovascular status, as the procedure may cause hemodynamic instability.
97. What are common symptoms after bronchoscopy that require monitoring?
Sore throat, mild cough, hoarseness, and minor blood-tinged sputum.
98. Why should bronchoscopy be avoided in patients with severe coagulopathy?
Because the risk of excessive bleeding during biopsy or lavage is significantly increased.
99. What role does bronchoscopy play in treating airway stenosis?
It allows for the placement of stents or laser therapy to open narrowed airways.
100. How is bronchoscopy used to manage mechanical ventilation patients?
It assists in secretion removal, diagnosing ventilator-associated pneumonia, and assessing airway integrity.
Final Thoughts
A bronchoscopy is a vital procedure for diagnosing and treating various respiratory conditions, and respiratory therapists play a crucial role in ensuring its success. From pre-procedural preparation and patient assessment to real-time monitoring and post-procedure care, RTs contribute significantly to patient safety and procedural efficiency.
Their expertise in airway management, oxygen therapy, and equipment operation helps optimize patient outcomes while minimizing risks.
As key members of the healthcare team, respiratory therapists provide essential support, making the procedure safer and more effective for both patients and healthcare providers.
Written by:
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
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- Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.
- Mahmoud N, Vashisht R, Sanghavi D, et al. Bronchoscopy. [Updated 2022 Sep 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
- Paradis TJ, Dixon J, Tieu BH. The role of bronchoscopy in the diagnosis of airway disease. J Thorac Dis. 2016.